Licenciado sob uma Licença Creative Commons DO): http://dx.doi.org. . / - . . .AO
[T]
Electrostimulation, response of the pelvic floor muscles, and
urinary incontinence in elderly patients post prostatectomy
[)]Eletroestimulação, resposta dos músculos do assoalho pélvico
e incontinência urinária em pós-prostatectomizados
[A]
Patrícia Zaidan[a], Elirez Bezerra da Silva[b]
[a] Specialist in Urogynecological Physical Therapy, University Gama Filho UGF - RJ , collaborator physical therapist of the
Outpatient Urogynecologic Physical Therapy of (ospital dos Servidores do Estado do Rio de Janeiro, Rio de Janeiro, RJ - Brazil, e-mail: [email protected]
[b] PhD in Physical Education, University Gama Filho UGF – RJ , coordinator of Post-Graduation Course in Physical Therapy
UGF , professor of the Post-Graduation stricto sensu Program in Sciences of the Exercise and Sports UGF , coordinator
of the Research Group Clinical School UGF , Rio de Janeiro, RJ – Brazil, e-mail: [email protected]
[R] Abstract
Objective: to investigate the response of the pelvic floor muscles PFM , and urinary incontinence U) , in
patients having undergone a prostatectomy, after treatment using electrical stimulation. Materials and methods: this observational study was conducted in an outpatient urogynecologic physical therapy clinic
of (ospital dos Servidores in Rio de Janeiro, Brazil from August to September . Ten patients aged, ± years with urinary incontinence resulting from radical prostatectomy, having received surgery within six months of study entry, without urinary infection, and without metallic implants underwent electrical stimu-lation of the PFM, while in lateral decubitus position with knees and hips flexed. The parameters used were
(z frequency, pulse width of μs, biphasic current, intensity according to the tolerance level reported by the patient, perineal contraction time of four seconds, and rest time of eight seconds for minutes twice a week, totaling sessions of electrical stimulation with active-assisted contraction. Patients were evaluated before and after electrical stimulation through physical therapy evaluation of urinary incontinence, by being asked about the number of disposable guards used daily, using a visual analogue scale VAS to measure how the U) interfered with activities of daily living, and by electromyographic biofeedback to measure the work of the PFM. Data were analyzed using Student’s paired t-tests and a significance level of . . Results:
increase in muscle strength of . ± . to . ± . μV t = - . , P = . , a significant decrease in the number of diapers used before and after treatment . ± . to . ± . , respectively; t = . , P = . , and a significant decrease in the interference of urinary incontinence on daily activities of . ± . to . ± . t = . , P = . . Conclusion: electrical stimulation may represent a novel way to strengthen
the pelvic floor muscles and decrease urinary incontinence resulting from radical prostatectomy. [P
]
Keywords: Urinary incontinence. Prostatectomy. Electric stimulation.
[B] Resumo
Objetivo: verificar a resposta dos músculos do assoalho pélvico (MAP) e da incontinência urinária (IU) em homens prostatectomizados após o uso da eletroestimulação como tratamento. Materiais e métodos: estudo observacional, realizado no ambulatório de fisioterapia uroginecológica do Hospital dos Servidores do Estado do Rio de Janeiro, no período de agosto a setembro de 2012. Dez pacientes com 64 ± 7 anos de idade, com incon-tinência urinária pós-prostatectomia radical, tempo máximo após cirúrgia de seis meses, sem infecção urinária e sem implante metálico foram submetidos à eletroestimulação dos MAP, que consistiu de um eletrodo endoa-nal (Dualpex 961 – Quark), com paciente na posição de decúbito lateral com joelhos e quadril flexionados. Os parâmetros utilizados foram frequência de 65 Hz, largura de pulso de 500 μs, corrente bifásica, intensidade de acordo com o nível de tolerância relatada pelo paciente, tempo de contração perineal de quatro segundos e tempo de repouso de oito segundos, durante 20 minutos, duas vezes semanais, totalizando 16 sessões de ele-troestimulação com contração ativa-assistida. Os pacientes foram avaliados antes e após a eletroestimulação por meio de relato sobre os ítens da avaliação fisioterapêutica da incontinência urinária, questionados sobre o número de protetores descartáveis utilizados diariamente, submetidos à escala visual analógica (EVA) para medir o quanto a IU interferia em suas atividades de vida diárias e ao biofeedback eletromiográfico para medir o trabalho dos MAP. Os dados foram analisados pelos teste t – student para amostras pareadas, para um nível de significância de 0,05. Resultados: após as 16 sessões de eletroestimulação a avaliação pelo biofeedback eletromiográfico mostrou um aumento significativo da força muscular de 10,73 ± 8,64 para 17,16 ± 9,00 μV (t = -3,39; P = 0,008), uma diminuição significativa do número de fraldas usadas antes e após o tratamento de 3,9 ± 1,2 para 1,8 ± 1,5 (t = 5,16; P = 0,0006), respectivamente e diminuição significativa da interferência da incontinência urinária nas atividades diárias de 9,6 ± 0,5 para 4,0 ± 3,8 (t = 5,15; P = 0,0006). Conclusão: a ele-troestimulação pode ser uma forma de reforçar a musculatura do assoalho pélvico e diminuir a incontinência urinária decorrente da pós-prostatectomia radical. [K]
Palavras-chave: Incontinência urinária. Prostatectomia. Estimulação elétrica.
Introduction
The prevalence of prostate cancer has been steadi-ly increasing in the recent years, and is a concern for both medical professionals and men in general. There are two main forms of prostate cancer, which may be benign, and are most commonly affecting men
aged and above . )n Brazil, prostate cancer
is one of the most common malignancies affecting
men, with an estimated , new cases of prostate
cancer diagnosed in , according to the Brazilian
National )nstitute of Cancer )NCA . )n , prostate
cancer was responsible for , deaths . Radical
prostatectomy is a common treatment option for lo-calized prostate cancer. Despite being highly effective, the procedure is associated with a number of issues such as bladder, intestinal, and sexual dysfunction due to complications of the surgery .
Urinary incontinence U) depends on the integ-rity of the internal and external sphincters, in addi-tion to the prostatic and membranous urethral seg-ments. )n turn, the function of the external sphincter is dependent on the proper functioning of its striated
muscle fibers . Despite recent improvements in
95
urinary incontinence after radical prostatectomy . Furthermore, treatment with biofeedback aims to promote an effective bladder emptying, as well as an appropriate continence, and to identify, locate, and ensure the muscle proprioception to achieve muscle coordination and rehabilitation, thus eliminating
in-adequate patterns of contractions .
The evaluation of the pelvic floor performed by electromyographic biofeedback is reproducible, and consistently predicts the clinical variables related to the functioning of these muscles. Electromyographic biofeedback is the method used to measure the mus-cle electrical activity, which is achieved by using an electrode capable of measuring spontaneous or
vol-untary activity of motor units .
The aim of this study was to determine the re-sponse of the pelvic floor muscles and potential changes in urinary incontinence status in prosta-tectomized men submitted to electric stimulation.
Materials and methods
Sample
Ten patients mean age, ± years old , who were evaluated for urinary incontinence post-radical prostatectomy who were within six months of their surgery, and who did not suffer urinary infection or had metallic implants, were enrolled in the study and followed at the outpatient Urogynecologic Physical Therapy Clinic of (ospital dos Servidores in the State of Rio de Janeiro (FSE , Brazil from August to
September .
All volunteers signed a consent form authoriz-ing the use of their information for research pur-poses. The authors received formal authorization from the head of the outpatient Urogynecology for the implementation of this study. This study
fol-lowed the rules of Resolution CNS / , and was
approved by the Ethics and Research Committee of the University Gama Filho protocol number
. . . .
Electrical activity of the pelvic l oor
The electromyographic biofeedback Miotool-uro
Miotec® , was used to measure the electrical activity
of the pelvic floor, before and after treatment. The affecting between and % of men ≥ months
af-ter surgery , .
After radical prostatectomy, urinary incontinence may ensue due to anatomical lesions, making the ure-throvesical junction less favorable for maintaining urinary continence, thus generating greater
pres-sure on the external urethral sphincter .Recent
advances in non-surgical treatments for urinary in-continence have yielded promising results, with a low rate of side effects, and reduced costs .
)n patients subjected to radical prostatectomy, postoperative urinary incontinence can have a sig-nificant effect on their quality of life. Over the last few years, many preventive measures have been de-scribed to decrease the risk of urinary incontinence after performing this surgery, including preoperative physiotherapy. Patients with urinary incontinence due to vesical instability are good candidates for physical therapy, and usually acquire continence within one year after surgery. (owever, patients who have persistent urinary incontinence are more
difficult to treat .Although urinary incontinence
does not put peoples’ lives at risk per se, it can have serious medical, social, psychological, and economic implications, thereby adversely affecting the quality
of life of the patients .
One of the main goals of urogynecological physi-cal therapy is to strengthen the pelvic floor muscles, thereby normalizing the function of these muscles and promoting their conscious and effective contrac-tions in moments of increased intra-abdominal
pres-sure, which prevents involuntary urinary leaks .
Besides strengthening of the pelvic floor muscle group by kinesiotherapy, physical therapeutic inter-vention in this condition can also comprise of
bio-feedback and functional electrical stimulation ,
and physical therapy is another therapeutic resource that uses efficient physical modalities in the
treat-ment of this pathology . Electrical stimulation
has shown promising results for the treatment of U), as it is able to re-educate the muscles of the pelvic floor. (owever, for it to achieve optimal results, it should be used in association with other
conserva-tive treatment methods .Electrical stimulation
offers muscle gain through cutaneous or endoanal devices, which works by promoting an increase in sphincter resistance and reductions in the
contrac-tion of detrusor muscle , Treatment with
evaluation mode was selected and all parameters were set to zero. We used an endoanal electrode, a surface electrode positioned over the sternum for reference, and two surface electrodes positioned on the infraumbilical region and rectus abdominis muscle bilaterally, aiming to control the relaxation of this muscle group. All electrodes were calibrated and coupled to a computer. The electrical activity of the pelvic floor was recorded graphically and numeri-cally on the computer, upon verbal request to the patient, in the lateral position, to perform a maximal voluntary contraction of the external anal sphincter muscle for three seconds.
Urinary incontinence
Urinary incontinence was measured by its inter-ference in daily life using a Visual Analogue Scale
VAS and questioning about the number of
disposable protectors used daily, before and after treatment. )n the implementation of VAS, the patient chose a score from to , where corresponds to "does not interfere" and corresponds to "inter-feres a lot".
Below is the VAS model used in the study:
Visual Analogue Scale (VAS)
minutes times weekly, totaling sessions of elec-trical stimulation with active-assisted contractions.
Data analysis
The results are presented as means ± standard deviation x ± SD . Paired Student’s t-tests, with a significance level of P < . , were used to test our hypothesis that increased electrical activity of the pel-vic floor results in decreased interference of urinary incontinence on daily life and in a reduction in the amount of disposable protectors used. All analyses
were performed using Statistica . Statsoft®, )nc,
- software.
Results and discussion
Electromyographic evaluation allows for the as-sessment of muscle electrical activity, enabling the capture of action potentials generated during
vol-untary contraction of the muscles . Besides
as-sessing the ability to contract, the electromyography records the contraction amplitude in microvolts μV , which can be considered as an indirect measure of
muscular strength .
The results obtained Table in this study showed a significant increase of % in the electrical
activ-ity of the pelvic floor muscles P = . Figure ,
significant reductions of % in the number of
dia-pers used P = . Figure , and of % in the
interference of urinary incontinence on daily
activi-ties P = . Figure , after sessions of
elec-trostimulation. The effect size of the electrical activity of the pelvic floor muscles was . , the effect size of the interference of urinary incontinence in daily life was . , and the effect size of used disposable protectors was . . )n general, the results were con-sidered satisfactory.
Electrical stimulation is recognized as a funda-mental therapy for reeducation of the sphincter and perineum, and works by promoting muscle contrac-tion and allowing the patients to become aware of
themselves . )n this study, the recruitment of
larger motor units fast fibers more likely to hy-pertrophy were favored, which, in voluntary
con-tractions, are difficult to recruit , . Another
advantage of the electrical stimulation was inhibi-tion of fatigue of the central nervous system, due to )n general, to what level does urinary
inconti-nence interfere with your everyday life? Please, circle a number between does not interfere to interferes a lot
Does not interfere inter-feres a lot
Endoanal electrostimulation
Patients underwent electrical stimulation using
an endoanal electrode Dualpex – Quark® in the
lateral position with knees and hips flexed accord-ing to patient comfort. The parameters used were
frequency of (z, pulse width of μs, biphasic
97 Table 1 - Mean and standard deviations of the electrical activity of the pelvic floor (EAPF), interference with daily life (IDL),
and amount of disposable protectors used before and after 16 sessions of endoanal electrostimulation
Factor Endoanal electrostimulation
Pre Post
EAPF (μV) 10.7 ± 8.6 17.2 ± 9.0*
IDL 9.6 ± 0.5 4.0 ± 3.8*
Disposable protectors 3.9 ± 1.2 1.8 ± 1.5*
Note: *: P < 0.05 regarding the pre-treatment values. Source: Research data.
simulation of the passage of nerve impulses, which subsequently led to muscle contractions without the need for an impulse from the nervous system itself. This made possible a higher number of repeti-tions and therefore a higher muscular work, apart
from enabling an isolated training . This was
due to the fact that electrical stimulation evokes action potentials in axons of alpha motoneurons, which are found in the peripheral nerves, allowing
the contraction of skeletal muscles . We here
found that electrical stimulation was a very use-ful complementary method of strength training, which increased not only the maximum stimulated strength, but also the voluntary strength, speed of
movement, and muscle endurance . )n this study
we used electrostimulation with active-assisted contraction as a way to strengthen the pelvic floor muscles, which, according to literature, allows the predominant recruitment of rapid fibers, since they are more superficial, where the electric current ar-rives more efficiently, which would take place with voluntary contraction if training was only between % and % of the maximum load, thus activat-ing all the slow fibers and most of the rapid fibers. The electrostimulation treatment performed in this study proved to be effective in recruiting both fast and slow fibers, hence allowing prompt and efficient
rehabilitation of the pelvic floor muscles , .
Urinary incontinence can be associated with more psychosocial devastating effects than health consequences per se, with multiple, and often com-prehensive, effects that can influence everyday ac-tivities, social interactions, and the self-perceived
health status . )n the present study, the
signifi-cant reduction in the use of diapers to contain the daily urine of . ± . to . ± . t = . ; P =
. likely contributed to the significant decrease
observed in the interference of urinary incontinence on the daily lives of people from . ± . to . ± .
t = . ; P = . .
The studies of Ribeiro et al. , Moore et al.
, Salinas et al. , Bales et al. , reinforce the
results found in this study. Ribeiro et al. conducted a randomized clinical trial to evaluate the efficiency of biofeedback in pelvic floor muscle training for the treatment of urinary incontinence in prosta-tectomized men. A total of patients were ran-domized into either a treatment group receiving biofeedback training of pelvic floor muscle once a week for months, as well as home exercises
n = , or a control group n = who did not
re-ceive formal education in training of the pelvic floor muscles. They were given brief verbal instructions by the urologist to contract the pelvic floor muscle, or were recommended a specific exercise program. At months post-surgery, . % of the participants from the treatment group, and % of the participants from
the control group were continent P = . , with
the duration of incontinence being lower month for the treatment group than for the control group months . These results indicate that strength training of the pelvic floor muscles with biofeedback can accel-erate the recovery of urinary continence after radical
prostatectomy within months post-surgery .
Moore et al. randomized participants to evalu-ate the effectiveness of electrical stimulation with or without muscle exercises for the pelvic floor, to treat urinary incontinence in post radical prostatectomy. )n weeks, the average loss of urine decreased
from g to g in their study, but there were no
P = . . Similar to our findings, urinary inconti-nence had a significant impact on the lives of the patients after radical prostatectomy. Quality of life was one of the outcomes measured in this study, as assessed by questionnaires ))Q- and EORTC QLQ C- , and the authors reported a significant improvement in urinary incontinence in patients assigned to the intervention group exercises for the pelvic floor muscles associated with electrical
stimulation .
Salinas et al. conducted clinical and
urody-namic studies with rectal electrical stimulation for urinary incontinence after prostatectomy in pa-tients with urinary incontinence, and obtained post-stimulation positive clinical results in % of cases. Thus, they concluded that this intervention was a
viable therapeutic alternative for U) .
On the other hand, the findings from studies
by Bales et al. and (unter et al. differed
from the results of the present study. Bales et al.
randomized men in a clinical trial to receive
training exercises for the pelvic floor muscles with biofeedback intervention or without biofeedback control , in both the pre- and postoperative stages
of prostatectomy, in order to improve urinary incon-tinence. Six months after surgery, the continence rates, as defined by the use of one diaper or less per day, were % and % in the biofeedback and
control groups, respectively P = . , suggesting
that no improvements were obtained from
preop-erative biofeedback training . (owever, in that
study, patients received both training of the pelvic floor muscles and verbal instructions from nurses, and were evaluated by questionnaires or phone calls, which may have influenced the results.
Finally, a recent systematic review by (unter
et al. evaluated conservative treatment,
con-sisting of training of the pelvic floor muscles with or without biofeedback, electrical stimulation, penile clamps, extracorporeal magnetic innervation, or a combination of these methods, for the treatment of post-prostatectomy urinary incontinence. Although the interventions were not directed to the strengthen-ing of the pelvic muscles, analyses of interventions such as electrical stimulation were inconclusive, and there were few data to determine the effects of treat-ment on incontinence. Most of these studies showed
a low-to-moderate quality .
Mean ± SD ±1,96*SD Pre Post
4 6 8 10 12 14 16 18 20 22 24
MVC (µV)
Figure 1 - Measurement of maximum voluntary contraction (MVC) by the electrical activity of the pelvic floor (μv = microvolt), before and after 16 sessions of endoanal electrostimulation (Student’s paired t-test, - 3.39; P = 0.008)
Note: SD: standard deviation. Source: Research data.
Pre Post 1
2 3 4 5 6 7 8 9 10
VAS
Mean ± SD ±1,96*SD
Figure 2 - Measuring of the interference of urinary inconti-nence in daily life using the visual analogue scale (VAS), before and after 16 sessions of endoanal electrostimulation (Student’s paired t-test, 5.15; P = 0.0006)
99
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. Johnson TM, Ouslander JG. Urinary incontinence in the older man. Med Clin North Am. ; : - . . (errmann V, Potrik BA, Palma PCR, Zanettini CL,
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Conclusion
The data obtained in this study indicate that elec-trostimulation may be a feasible way to strengthen the pelvic floor muscles and decrease urinary inconti-nence and the associated interference in the daily lives of people having undergone radical prostatectomy.
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